To take a statin, or not to take a statin? Current UK guidance now advocates offering the cholesterol-lowering drugs to everyone at 10% or higher risk of having a stroke or heart attack over the next decade. A slim, non-smoking, healthy man is likely to reach this threshold in his late fifties, while a typical woman will be there by her early sixties. So, should you take one?
Read on to see what I think everyone should know before deciding…
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How do statins help?
Statins lower blood cholesterol levels associated with the ‘furring’ of arteries that eventually leads to most strokes and heart attacks. But that is not the whole story. They seem to work in other ways too – probably by reducing inflammation and stabilising deposits on the arterial wall so they are less likely to tear or break off (the classic precipitating event for most heart attacks).
This stabilising mechanism may be the important one – perhaps explaining why plant stanol and sterol cholesterol-lowering drinks and dairy spreads reduce cholesterol but have yet to be shown convincingly to protect against heart disease.
Do statins work?
Whatever the exact mode of action, statins do work. The average person on a statin can expect their cholesterol to fall by around a quarter and their risk of heart attack and stroke over the next five years to reduce by a similar degree.
A significant protective effect if you are a 60-year-old smoker recovering from your first heart attack, but of negligible benefit if you are a clean-living 65-year-old marathon runner. Or, to put it another way, a quarter of a lot is worth having, but a quarter of nothing is not.
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Cholesterol: what it does and why some of us have too much
Cholesterol is such an essential component of so many systems in the body – from hormones to cell walls and nerves – that we all have our own in-built manufacturing and recycling processes to ensure there is always enough.
Our diet contains surprisingly little of this fat-like substance, and dietary cholesterol intake is not as strongly linked to heart disease as most people believe (early research suggesting it was is now regarded as flawed).
Cholesterol is a part player in a complex system and just because it is easy to measure and we have statins to reduce it, doesn’t make it any more important than other factors such as smoking, blood pressure and family history. Indeed, it is often less so.
But despite dietary cholesterol intake not making that much difference, most of us still have higher-than-ideal cholesterol levels. So where is it all coming from?
You are making much of it. Genetic variation in our bodies’ manufacturing and recycling process – some of us are too efficient at both – accounts for many of the high cholesterol levels that we see when people are tested.
What you need to know about cholesterol
Focus on cardiovascular risk
I spend much more time considering my patients’ risk of having an early stroke or heart attack than I do their cholesterol results. Like most GPs, I use the online calculator at qrisk.org to work out the likelihood of someone having a stroke or heart attack in the next decade. It’s only a guesstimate, based on things such as family history, height and weight, blood-test results and the presence of other risk factors such as diabetes, but it’s the best guide we have.
You can use it too, to calculate your risk and see how changes such as losing weight, reducing blood pressure, stopping smoking and improving your cholesterol profile might influence your odds of running into trouble over the next ten years. Doctors consider a risk of 10% or more an indication to discuss statins, while over 20% is deemed to be high risk.
Self-help measures you can take to reduce your heart risk
Before your doctor reaches for the prescription pad, ask what you can do yourself. Most dietary and lifestyle interventions are more protective than statins and have myriad other benefits too. Being told you are at moderate or high risk should be a wake-up call to think about self-help – not a reason, necessarily, to take a statin. Treat cholesterol-lowering drugs as a supplement to, rather than a substitute for, healthy living.
Natural alternatives to statins
Your first reaction should be to look at other measures that will protect you, for example:
- lose weight if you are carrying too much
- start an exercise programme
- stop smoking
- eat healthily by cutting back on excessive carbs, particularly sugars, and following a Mediterranean-style diet
10 superfoods that help lower bad cholesterol
This won’t just reduce your risk of cardiovascular disease, but could help ward off cancers too, as well as improving your sense of wellbeing and helping with the management of common accompanying health problems such as diabetes and high blood pressure. You can always polish the diamond by adding a statin.
And don’t expect statins to work miracles. At least 100 otherwise healthy people have to take the drugs for five years to prevent just one of them having a heart attack – a surprisingly small benefit that has to be balanced against the risk of side effects. Most people on statins are not troubled by side effects, but equally most of them don’t benefit either.
The possible side effects of statins
Which statin at what dose?
Atorvastatin is the favoured first-line option these days, ranging from 20mg a day for primary prevention (otherwise well and no pre-existing cardiovascular disease) to 80mg a day for secondary prevention (eg, after a heart attack).
Possible side effects of statins
Statins are generally very well tolerated but they can cause side effects. Some of the more common complaints include:
- flatulence and an upset stomach
- sleep disturbance
- aching muscles
The latter should always be reported to your GP as it can, rarely, be a sign of a serious reaction.
Some patients, particularly older ones, complain of mental fogging and poor memory although statins may not be to blame. Long-term use has been linked to diabetes and cataracts.
Measuring cholesterol levels
It is generally accepted that a good blood test result is a total cholesterol (TC) level of less than 5mmol/litre, but don’t be disappointed if your level is higher, as most people tend to have a TC in the 5 to 6.5 range.
Ideal levels of HDL ‘good cholesterol’ are more than 1mmol/litre for a man and more than 1.2mmol/litre for a woman.
Be aware a blood test is just a one-off snapshot of a profile that is constantly altering. Levels often vary by as much as 5% from day to day, and by up to 10% across the year (typically highest during winter).
Age also makes a difference. Levels rise during the first few decades of adult life, peaking in the forties and fifties in men, and sixties and seventies in women. After which they gradually drop again.
If your blood test result comes back very high (TC 7.5 plus), ask your doctor about repeat testing and further investigations. But don’t be too worried by readings in the 5s or 6s. As long as your overall risk is low, these are unlikely to be important.